Surgical management of Upper urinary tract calculi m.h.izadpanahi, md, febu Fellowship of urologic oncology IUMS, Isfahan, iran

background Kidney stones are common and costly Affect 10% of population Prevalence rates are increasing Cost> US $2 billion per year

Rationale for tx Nonstaghorn Renal Calculi First, stone-related symptoms or stone growth, with a calculated risk of approximately 50% at 5 years. Second, spontaneous stone passage occurs about 15% of the time and is more likely in stones 5 mm in size or smaller.

Staghorn stones Untreated staghorn stones are associated with 1- recurrent UTIs 2- urosepsis events 3- renal functional deterioration, and a higher likelihood of death Complete renal function loss in 50% of affected kidneys can occur after 2 years without treatment

modalities ESWL URS or RIRS PCNL laparoscopic or robotic assisted stone surgery

ESWL(mechanism of action) All shock waves, despite their source, are capable of fragmenting stones when focused Fragmentation is achieved by several mechanisms forces result in erosion at the entry and exit sites of the shock wave

ESWL

Postoperative care active ambulatory status to facilitate stone passage Gross hematuria should resolve during the first postoperative week Fluid intake should be encouraged Follow-up in approximately 2 weeks for discussion and evaluation of a KUB and renal ultrasonography

ESWL(complications) perirenal hematomas:Severe pain unresponsive to routine intravenous or oral medications(Dx=CT) Steinstrasse (stone street) Stone residue(depends on the size and location of stone)

URS or TUL

TUL

lithoclast

PNL

PNL

PNL

PNL

PNL

PNL

ESWL and PCNL outcomes

Staghorn Stones. PCNL is the method of choice for treating partial and complete staghorn kidney stones Observation and nonoperative management should be discouraged, because eventually cause complete loss of function in the affected kidney, can be the cause of recurrent UTIs and sepsis episodes, and are associated with an increased overall mortality

URETERAL CALCULI the chief determinant of stone passage: 1- is the diameter of the stone in its transverse orientation . 2- the location of the stone within the ureter at presentation with a review of the literature demonstrating a 71% chance of passage of a distal ureteral stone versus 22% for proximal stones

For stones that do not move in a reasonable time frame, or in the setting of recurring severe pain, or if the patient prefers, surgical therapy is indicated. Primary options include SWL and URS, although PCNL and antegrade nephroscopy may be indicated for select cases

Distal Ureter. As discussed earlier, distal stones are most likely to pass with observation or MET . The most typical site for impaction in this region of the ureter is at the UVJ; stones reaching this location often cause significant irritative symptoms owing to stimulation of the bladder, a clinical sign that helps localize them. When stones fail to pass, once again surgical therapy is indicated.

A UTI associated with an obstructing upper tract stone (ureteral or renal) represents a true urologic emergency and requires emergent urinary tract drainage. This is accomplished by either ureteral stenting or percutaneous nephrostomy. Attempts to definitively treat the obstructing stone should be postponed until the patient is stabilized and the infection is completely treated.78

Renal Function The general consensus is that symptomatic upper tract stones located in renal units with approximately 15% or less split function should be considered for nephrectomy, and stone-specific, nephron-sparing treatments should not be pursued.

Morbid Obesity A BMI above 40 kg/m2 is considered morbid obesity by the World Health Organization. Ureterorenoscopy and PCNL outcomes appear to be relatively independent of obesity status, whereas those after SWL are drastically worse.

Old Age and Frailty A number of groups have looked at PCNL outcomes in elderly populations and have found essentially unchanged surgical success, albeit with a higher rate of complications.Shock wave lithotripsy in the elderly is feasible as well, but it may be associated with an increased risk of perinephric hematoma.

Uncorrected Coagulopathy Uncorrected coagulopathy is a contraindication to SWL and PCNL; however, URS can be successfully undertaken in such circumstances with little to no increase in surgical morbidity.

Prior Renal Surgery Prior renal surgery is not a contraindication to any form of renal stone surgery and presents no new specific concerns. Thus, all treatment modalities may be employed as necessary, given appropriate indications (SWL, URS, PCNL).

Renal Transplants because of the lack of innervation in renal transplants, obstructing stones do not manifest with typical renal colic. vague graft site discomfort, fevers, oliguria, hematuria, or rising creatinine may be the only presenting signs

SWL has been described for stones in transplant kidneys and is an option for stones smaller than 1.5 cm; however, high re-treatment rates and auxiliary procedure rates should be expected

PCNL remains the preferred treatment choice for large-burden stones (>1.5 cm) or if less invasive methods have failed. Stone-free rates ranging from 77% to 100%, similar to rates in the general population, have been reported

Evaluation of Outcome Assessment and Fate of Residual Fragments In the modern era with the rise of endourology and the frequent use of SWL, URS, and PCNL, postoperative residual fragments are relatively common. The definition and optimal management of residual fragments continue to generate controversy.